Measuring access to effective care among elderly medicare enrollees in managed and Fee-for-Service care: a retrospective cohort study

Accounting for uncertainty in policy decision making: Improving access to pediatric dental care

OBJECTIVE

To introduce a statistical inference framework for policy decision making on access to pediatric dental care.

DATA SOURCES

Secondary data were collected for the state of Colorado for year 2019.

STUDY DESIGN

The access model was an optimization model, matching the demand (patients) and supply (providers) of dental care. Sampling distributions of model inputs were specified using hierarchical Bayesian models, with hyperparameters informed by prior information derived from multiple data sources. Simultaneous inference was applied to identify areas for access improvement. The model was applied to make inference on the pediatric dental care in Colorado, accounting for financial access, differentiated into public (Medicaid and CHIP), private (commercial and out-of-pocket), and without financial access.

DATA COLLECTION/EXTRACTION METHODS

Multiple data sources informed the access measurement approach including: 2017 American Community Survey, 2019 Colorado Dental Board, and 2019 National Provider Plan and Enumeration System, 2019 InsureKidsNow.gov among others.

PRINCIPAL FINDINGS

The median access measure (travel distance) was greater than the Colorado access standards in 16.9% and 65.1% of census tracts for children with private financial access and publicly insured, respectively. Accounting for uncertainty (confidence level 99%), these percentages decreased to 14.6% and 25.6%, respectively, with mostly suburban and rural tracts failing to meet the standards. The median disparity for Medicaid and CHIP versus private financial access was greater than 5 miles in 84.5% and 81.6% of census tracts, respectively. Accounting for uncertainty (confidence level 99%), these percentages declined to 19.5% and 10.5%, respectively, with significant disparities around the metropolitan areas.

CONCLUSIONS

While many communities failed to meet access standards, when accounting for uncertainty, most urban ones did not fail. Disparities in spatial access between publicly and privately insured were most acute in urban communities. Medicaid insured experienced higher disparities than CHIP insured; those differences were not identified when not accounting for uncertainty.

Reliability of medical group and physician performance measurement in the primary care setting

BACKGROUND

Performance reporting is increasingly focused on physician practice sites and individual physicians.

OBJECTIVE

To assess the reliability of performance measurement for practice sites and individual physicians.

RESEARCH DESIGN

We used data collected across multiple payers as part of a statewide measurement collaborative to evaluate the observed measure reliability and sample size requirements to achieve acceptable reliability of 4 Health Care Effectiveness Data and Information Set measures of preventive care and 10 Health Care Effectiveness Data and Information Set measures of chronic care across 334 practice sites. We conducted a parallel set of physician-level analyses using data across 118 primary physicians practicing within a large multispecialty group.

MEASURES

Observed reliabilities and estimated sample size requirements to achieve reliability ≥0.70.

RESULTS

At the practice site level, sample sizes required to achieve a reliability of 0.70 were less than 200 patients per site for all 4 measures of preventive care, all 4 process measures of diabetes care, and 2 outcomes measures of diabetes care. Larger samples were required to achieve reliability for cholesterol screening in the presence of cardiovascular disease (n = 249) and use of appropriate asthma medications (n = 351). At the physician level, less than 200 patients were required for all 4 measures of preventive care, but for many chronic care measures the samples of patients available per physician were not sufficient to achieve a reliability of 0.70.

CONCLUSION

In a multipayer collaborative, sample sizes were adequate to reliably assess clinical process and outcome measures at the practice site level. For individual physicians, sample sizes proved adequate to reliably measure preventive care, but may not be feasible for chronic care assessment.

Medicare managed care enrollment by disability-eligible and age-eligible veterans

OBJECTIVE

To assess factors associated with enrollment in a Medicare advantage (MA) plan versus Medicare fee-for-service plan in 2000-2004 by Medicare-eligible veterans. We also assessed whether these factors differed between disability-eligible veterans and age-eligible veterans.

METHODS

Medicare claims data, VA administrative data, and 2000 census data were constructed in a retrospective cohort study of 20,581 age-eligible veterans and 7541 disability-eligible veterans. MA enrollment in 2000-2004 was estimated in a logistic regression in a pooled sample of age-eligible and disability-eligible veterans that controlled for demographic, socioeconomic, and disease risk factors. Separate logistic regressions also were estimated for age-eligible and disability-eligible veterans.

RESULTS

Minority veterans and veterans with lower disease risk scores were more likely to be enrolled in an MA plan in 2000-2004 than white veterans or veterans with higher risk scores. Age-eligible veterans were more likely to be enrolled if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid. Disability-eligible veterans were more likely to be enrolled if they were married or elderly.

CONCLUSIONS

Medicare Advantage plans appeared to benefit from favorable selection of Medicare-eligible veterans.

Quality monitoring of physicians: linking patients' experiences of care to clinical quality and outcomes

BACKGROUND

Physicians are increasingly asked to improve the delivery of clinical services and patient experiences of care.

OBJECTIVE

We evaluated the association between clinical performance and patient experiences in a statewide sample of physician practice sites and a sample of physicians within a large physician group.

DESIGN, SETTING, PARTICIPANTS

We separately identified 373 practice sites and 119 individual primary care physicians in Massachusetts.

MEASUREMENTS

Using Health Plan Employer Data and Information Set data, we produced two composites addressing processes of care (prevention, disease management) and one composite addressing outcomes. Using Ambulatory Care Experiences Survey data, we produced seven composite measures summarizing the quality of clinical interactions and organizational features of care. For each sample (practice site and individual physician), we calculated adjusted Spearman correlation coefficients to assess the relationship between the composites summarizing patient experiences of care and those summarizing clinical performance.

RESULTS

Among 42 possible correlations (21 correlations involving practice sites and 21 involving individual physicians), the majority were positive in site level (71%) and physician level (67%) analyses. For the 28 possible correlations involving patient experiences and clinical process composites, 8 (29%) were significant and positive, and only 2 (7%) were significant and negative. The magnitude of the significant positive correlations ranged from 0.13 to 0.19 at the site level and from 0.28 to 0.51 at the physician level. There were no significant correlations between patient experiences and the clinical outcome composite.

CONCLUSIONS

The modest correlations suggest that clinical quality and patient experience are distinct, but related domains that may require separate measurement and improvement initiatives.

Socioeconomic Disparities in Medical Provider Visits among Medicare Managed Care Enrollees

This study examined socioeconomic disparities in medical provider visits for elderly people enrolled in two Medicare managed care plans. Controlling for health and demographic differences, elderly people of lower income had fewer primary care visits and those with lower education had fewer specialist visits. The number of emergency room visits was not significantly related to socioeconomic status (SES). People of low SES reported having more financial barriers to receiving care and greater difficulties navigating the managed care system than people of high SES. Further, elderly people of low SES had different degrees of belief in the efficacy of the medical system and of lifetime experiences with a usual source of medical care prior to Medicare, both of which were associated with differential use of medical providers.

Predictors of preventive service use among Medicare beneficiaries

Despite Medicare coverage, receipt of clinical preventive services is suboptimal. Using multivariate regression analyses and Medicare Current Beneficiary Survey (MCBS) data for 2001, we estimated the relationship between the number of preventive services received in the 12-month recall period and: socioeconomics, plan type, health status, health risks, and ability to address daily needs. Results are nationally representative for the study year. With the exception of blood pressure and cholesterol screening, approximately one- to two-thirds of Medicare beneficiaries did not receive recommended preventive services. Strategies should be developed to ensure appropriate use of preventive services over time.